THE ROLEOF THE

THE MISSING LINK

SPECIALTYPHARMACY

THE IMPORTANCEOF OUR

MICROBIOME

FATTY LIVER DISEASE

SUMMER 2016

BLOATING &SUCROSEINTOLERANCE:

NON-ALCOHOLIC

NaomiJudd

gut GI bleeding,diarrhea

abdominal pain,constipation,

gas

nausea,vomiting

What’s your telling you?

Cramps, bloating, vomiting, diarrhea, nausea and sharp abdominal pain can have other serious reasons lurking behind them. When home remedies and over-the-counter laxatives, pain relievers and antacids don’t seem to work, listen to your gut—visit our ER immediately.

When it goes beyond “was it something I ate” to “OMG, this is unbearable,” it’s time to visit the ER.

For answers to your health questions or a FREE physician referral, call 305-480-6666 or visit MiamiDadeHospitals.com.

Text ER to 32222* to see average wait times.Message & Data Rates May Apply. Terms & Conditions http://www.texterhelp.com/. Privacy Policy http://www.HCAEastFlorida.com/.

gut

MISSIONTo provide outstanding medical care and an exceptional healthcare experience.

GUIDING PRINCIPLEWe will treat each patient as a valued member of our immediate family.

Care and CompassionProvide competent, individualized care in a professional, respectful and caring way.

TeamworkRecognize each other as valuable members of our healthcare team by treating one another with loyalty, respect and dignity.

Responsibility Provide excellent and efficient administrative, accounting, personnel and business management services.

Value and ExcellenceDevelop valuable ancillary services that improve our patients’ quality of care and customer experience.

Honesty and IntegrityCommunicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards.

StewardshipAttract and retain great talent and the finest gastroenterologists by actively promoting a professionally satisfying work environment.

AccountabilityMaintain mutually beneficial relationships with top referring physicians, payers, employers and health systems using performance, outcome, as well as satisfaction measurements to demonstrate accountability and improvement in our care delivery.

CORE VALUES

Caring for you and those you love.

gut GI bleeding,diarrhea

abdominal pain,constipation,

gas

nausea,vomiting

What’s your telling you?

Cramps, bloating, vomiting, diarrhea, nausea and sharp abdominal pain can have other serious reasons lurking behind them. When home remedies and over-the-counter laxatives, pain relievers and antacids don’t seem to work, listen to your gut—visit our ER immediately.

When it goes beyond “was it something I ate” to “OMG, this is unbearable,” it’s time to visit the ER.

For answers to your health questions or a FREE physician referral, call 305-480-6666 or visit MiamiDadeHospitals.com.

Text ER to 32222* to see average wait times.Message & Data Rates May Apply. Terms & Conditions http://www.texterhelp.com/. Privacy Policy http://www.HCAEastFlorida.com/.

gut

Index Pages

9500 South Dadeland Boulevard Suite 200, Miami, FL 33156T. 305.468.4180w w w . g a s t r o h e a l t h . c o m

Designed and Published by:

11900 Biscayne BoulevardSuite 100, Miami, FL 33181T. 305.820.0690info@creativemindworks.com

All rights reserved.

TM

Cover Photo Credit: Europa Press /Getty Images

Copyright © 2015 Gastro Health, P.L. All rights reserved. This publication is published by Gastro Health, P.L., which is solely responsible for its contents. This information presented is intended only for residents of the United States. The material presented is intended only as informational, or as an educational aid, and it is not intended to be taken as medical advice. The ultimate re-sponsibility for patient care resides with a healthcare professional.

This issue of the Gastro Health Magazine features Naomi

Judd, a well-known country singer, baby boomer and

Hepatitis C survivor. Before rising to fame Naomi was an

intensive care nurse in Nashville, TN who unknowingly

contracted Hep C while treating ICU patients. Upon

leaving the medical profession and entering into a five

year glamorous but exhausting journey into the world

of entertainment, she suddenly fell ill.

She is now a strong voice for Hepatitis C awareness,

ambassador for further research and education of

the benefits of positive thinking to help the recovery

process. It’s important to highlight that the CDC

is recommending that everyone born during 1945

through 1965, also known as baby boomers, get a

blood test for Hepatitis C. If you are a baby boomer

the CDC recommends a one-time test.

In addition, other articles of interest in this issue are;

“The Importance of Our Microbiome,” “The Role of

Specialty Pharmacy at Gastro Health” and “Non-

Alcoholic Fatty Liver Disease (NAFLD).”

As we are at the midpoint of 2016, we are continuing

our strategy of growth at Gastro Health, not

only providing outstanding medical care and

an exceptional healthcare experience, but also

identifying opportunities to improve services for

you and your family.

Thank you for your unwavering confidence. We hope

you have a safe and fun-filled summer.

Alejandro Fernandez MBA, CMPE

Chief Executive Officer

Gastro Health Welcomes You

NAOMI JUDD: SINGER, SONGWRITER AND SURVIVORby Michelle Menendez

BLOATING & SUCROSE INTOLERANCE: THE MISSING LINKby Enrique Hernandez-Sanchez, MD

14

GH CLINICAL UPDATEby Jerry Martel, MD

13

PARTICIPATE IN CLINICAL RESEARCH & HELP MAKE A DIFFERENCE FOR THE FUTURE by Howard Schwartz, MD

19

THE IMPORTANCE OF OUR MICROBIOMEby Paul G. Fishbein, MD

20

THE ROLE OF THE SPECIALTY PHARMACYby Katiuska Iglesias, PharmD

24

NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)by Somal S. Shah, MD

22

4

Track, Share, and Compare

Better monitor your

IBD health

Introducing Gut CheckTM: One-of-a-kind supportfor your inflammatory bowel disease (IBD)

© Janssen Biotech, Inc. 2015 12/15 043635-151119

To learn more, visit www.MyGutCheckApp.com

Record how you’re doing via surveys and

the Health Tracker

Compare how you’re doing against other Gut

Check users

Automatically share your data with your doctor

Download the free app today and get started!

Monitor your IBD and get the most out of your doctor visits

Daily health tracker

Bathroom finder

Validated surveys

Diet tips

Appointment calendar

Tokens and user rankings

Features include:

4

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aomi Judd has lived a successful

life comprised of several careers,

singing and songwriting making

her name synonymous with fame.

Originally a single mom from a small-

town in Kentucky, she went on to

become a nurse at intensive care

units in Nashville, Tennessee

where it was routine to be

stuck with needles or get

bodily fluids on herself.

Naomi Judd: Singer, Songwriter and Survivor

N

5

In 1984, Naomi made a decision to

leave the medical field and enter the

more glittery and glamorous world

of entertainment. She looked good

and felt even better as she performed

alongside her daughter and singing

partner Wynonna Judd. Together they

went on several tours and sang at

the Super Bowl halftime, the London

Palladium, Madison Square Garden

and even Carnegie Hall. They sold

20 million records, made 15 #1 hits

and received more than 60 awards

including six Grammys and seven CMA

Vocal Group of the Year trophies. They

were unstoppable for five years until

1989, when Naomi started losing her

energy at a drastic rate.

Naomi’s symptoms came in the form

of exhaustion, headaches, nausea and

muscle aches. She decided to visit one

of the doctors she had known from

years past and after an analysis was

told that her ALT/AST liver enzymes

were a little elevated. The doctor made

nothing serious of it, as he believed

that her strenuous lifestyle was most

likely the cause. But knowing herself

and her body very well, Naomi knew

something was off. It was then that

the head of her record label made an

appointment for her at the Mayo Clinic

where it was concluded that she had

contracted Hepatitis C, most possibly

from an infected needle while working

as a nurse. She was given three years

to live and was forced to say goodbye

to her fans.

Initial treatment consisted of Interferon

injections three times a week. Doctors

advised the treatment would slow

down the mutation and replication

of hepatitis C but not cure it. The

side effects were off-putting and

comparable to a having a severe

flu. There were times Naomi was

so weak she couldn’t even get out

of bed or change her clothes. With

unwavering determination she

continued treatment even when the

hepatits C seemed to outwit the

Interferon. Within a matter of time a

newer version of the medication was

released, and in 1995 Naomi received

the call she had been waiting for and

was told she was completely cured.

The experience changed her life and

led her to become an advocate of

health and wellness as a form of self-

empowerment. In 2004 she published

a New York Times bestseller “20

Choices to Transform Your Life,” and

in 2008, “Naomi’s Guide to Aging

Gratefully: Facts, Myths, and Good

News for Boomers.” She has also had

her own docu-series on OWN, the

Oprah Winfrey Network, and her own

radio show “Think Twice” on SiriusXM

radio series.

By Michelle Menendez

“I’m radiantly healthy and happier

than ever, and I’m using my

restored energy to help others

learn about themselves.”

* In a study of 865 patients with genotype 1 Hep C and no prior Hep C treatment, with or without advanced liver disease (cirrhosis), 99% (210 out of 213) of those who received HARVONI once daily for 12 weeks were cured. In a separate study of 647 patients with genotype 1 Hep C, with no prior Hep C treatment and without cirrhosis, 96% (208 out of 216) of those who received HARVONI once daily for 12 weeks were cured.

† In the study of 647 patients with genotype 1 Hep C, with no prior Hep C treatment and without cirrhosis, 97% (119 out of 123) of those with lower levels of the virus (less than 6 million IU/mL) who received HARVONI once daily for 8 weeks were cured.

These studies did not include patients with liver failure or those who have had a liver transplant.

‡ Based on prescription data for U.S. patients starting Hep C treatment with advanced treatment regimens (including direct-acting antiviral medicines) from 5/2011–12/2015. ∂

TO BE

I AM

UREDIn clinical studies, 96–99% of patients with genotype 1 who had no prior treatment were cured with just 12 weeks of therapy.*

TODAY THERE’S HARVONI. A BREAKTHROUGH TREATMENT FOR HEPATITIS C. Now, more people have been prescribed HARVONI to cure their Hep C than any other advanced treatment regimen.‡

HARVONI is a prescription medicine used with or without ribavirin to treat chronic (lasting a long time) hepatitis C (Hep C) genotype 1, 4, 5 or 6 infection. It is not known if HARVONI is safe and eff ective in children under 18 years of age.

HARVONI has been proven to cure up to 99% of patients with genotype 1 (the most common type of hepatitis C) who’ve had no prior Hep C treatment.*

HARVONI transformed Hep C treatment as the fi rst cure that’s one pill, once a day for 12 weeks. And for certain patients with genotype 1, HARVONI has been shown to be highly eff ective in as little as 8 weeks of treatment.† Your Hep C Specialist will decide what treatment length is right for you.

Cure means the Hep C virus is not detected in the blood when measured three months after treatment is completed.

With HARVONI, there’s no interferon and no complicated regimens.

So, if you don’t want to live with the uncertainties of Hep C, now may be the time to talk to your Hep C Specialist about HARVONI.

IMPORTANT SAFETY INFORMATIONWhat should I tell my healthcare provider before taking HARVONI?

• If you have: liver problems other than hepatitis C infection, or have had a liver transplant; severe kidney problems or are on dialysis; HIV, or any other medical condition; or if you are pregnant or breastfeeding or plan to become pregnant or breastfeed. It is not known if HARVONI will harm your unborn baby or pass into your breast milk. If you take HARVONI with ribavirin, you should also read the ribavirin Medication Guide for important pregnancy-related information.

• Tell your healthcare provider and pharmacist about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. HARVONI and certain other medicines may aff ect each other, or may cause side eff ects. Tell your healthcare provider if you take any medicines containing tenofovir disoproxil fumarate (ATRIPLA®, COMPLERA®, STRIBILD®, TRUVADA®, VIREAD®).

What are the possible side eff ects of HARVONI?• HARVONI, when taken with amiodarone (Cordarone®, Nexterone®, Pacerone®), a medicine used

to treat certain heart problems, may cause serious side eff ects, including slow heart rate, which in some cases has led to death or the need for a pacemaker. Get medical help right away if you take amiodarone with HARVONI and get any of the following symptoms: fainting or near-fainting, dizziness or lightheadedness, not feeling well, weakness, extreme tiredness, shortness of breath, chest pains, confusion, or memory problems.

• The most common side eff ects of HARVONI include tiredness, headache and weakness.

You are encouraged to report negative side eff ects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Are you ready for HARVONI? Ask your Hep C Specialist if HARVONI is right for you and visit HARVONI.com or call 1-844-READY41.

Please see Important Facts about HARVONI on the following page.

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* In a study of 865 patients with genotype 1 Hep C and no prior Hep C treatment, with or without advanced liver disease (cirrhosis), 99% (210 out of 213) of those who received HARVONI once daily for 12 weeks were cured. In a separate study of 647 patients with genotype 1 Hep C, with no prior Hep C treatment and without cirrhosis, 96% (208 out of 216) of those who received HARVONI once daily for 12 weeks were cured.

† In the study of 647 patients with genotype 1 Hep C, with no prior Hep C treatment and without cirrhosis, 97% (119 out of 123) of those with lower levels of the virus (less than 6 million IU/mL) who received HARVONI once daily for 8 weeks were cured.

These studies did not include patients with liver failure or those who have had a liver transplant.

‡ Based on prescription data for U.S. patients starting Hep C treatment with advanced treatment regimens (including direct-acting antiviral medicines) from 5/2011–12/2015. ∂

TO BE

I AM

UREDIn clinical studies, 96–99% of patients with genotype 1 who had no prior treatment were cured with just 12 weeks of therapy.*

TODAY THERE’S HARVONI. A BREAKTHROUGH TREATMENT FOR HEPATITIS C. Now, more people have been prescribed HARVONI to cure their Hep C than any other advanced treatment regimen.‡

HARVONI is a prescription medicine used with or without ribavirin to treat chronic (lasting a long time) hepatitis C (Hep C) genotype 1, 4, 5 or 6 infection. It is not known if HARVONI is safe and eff ective in children under 18 years of age.

HARVONI has been proven to cure up to 99% of patients with genotype 1 (the most common type of hepatitis C) who’ve had no prior Hep C treatment.*

HARVONI transformed Hep C treatment as the fi rst cure that’s one pill, once a day for 12 weeks. And for certain patients with genotype 1, HARVONI has been shown to be highly eff ective in as little as 8 weeks of treatment.† Your Hep C Specialist will decide what treatment length is right for you.

Cure means the Hep C virus is not detected in the blood when measured three months after treatment is completed.

With HARVONI, there’s no interferon and no complicated regimens.

So, if you don’t want to live with the uncertainties of Hep C, now may be the time to talk to your Hep C Specialist about HARVONI.

IMPORTANT SAFETY INFORMATIONWhat should I tell my healthcare provider before taking HARVONI?

• If you have: liver problems other than hepatitis C infection, or have had a liver transplant; severe kidney problems or are on dialysis; HIV, or any other medical condition; or if you are pregnant or breastfeeding or plan to become pregnant or breastfeed. It is not known if HARVONI will harm your unborn baby or pass into your breast milk. If you take HARVONI with ribavirin, you should also read the ribavirin Medication Guide for important pregnancy-related information.

• Tell your healthcare provider and pharmacist about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. HARVONI and certain other medicines may aff ect each other, or may cause side eff ects. Tell your healthcare provider if you take any medicines containing tenofovir disoproxil fumarate (ATRIPLA®, COMPLERA®, STRIBILD®, TRUVADA®, VIREAD®).

What are the possible side eff ects of HARVONI?• HARVONI, when taken with amiodarone (Cordarone®, Nexterone®, Pacerone®), a medicine used

to treat certain heart problems, may cause serious side eff ects, including slow heart rate, which in some cases has led to death or the need for a pacemaker. Get medical help right away if you take amiodarone with HARVONI and get any of the following symptoms: fainting or near-fainting, dizziness or lightheadedness, not feeling well, weakness, extreme tiredness, shortness of breath, chest pains, confusion, or memory problems.

• The most common side eff ects of HARVONI include tiredness, headache and weakness.

You are encouraged to report negative side eff ects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Are you ready for HARVONI? Ask your Hep C Specialist if HARVONI is right for you and visit HARVONI.com or call 1-844-READY41.

Please see Important Facts about HARVONI on the following page.

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POSSIBLE SIDE EFFECTS OF HARVONI

HARVONI, when taken with amiodarone (Cordarone®, Nexterone®, Pacerone®), a medicine used to treat certain heart problems, may cause serious side effects, including slow heart rate, which in some cases has led to death or the need for a pacemaker. Get medical help right away if you take amiodarone with HARVONI and get any of the following symptoms: • fainting or near-fainting• dizziness or lightheadedness• not feeling well• weakness• extreme tiredness• shortness of breath• chest pains• confusion• memory problems

The most common side effects include tiredness, headache and weakness.

These are not all the possible side effects of HARVONI. Tell your healthcare provider if you have any new symptoms while taking HARVONI.

GET MORE INFORMATION

• This is only a brief summary of important information about HARVONI. Talk to your healthcare provider or pharmacist to learn more.

• Go to HARVONI.com or call 1-844-READY41 • If you need help paying for your medicine call

1-855-7-MYPATH or go to HARVONI.com/support

BEFORE TAKING HARVONI

Tell your healthcare provider if you have:• Liver problems other than hepatitis C infection• Had a liver transplant • Severe kidney problems or you are on dialysis• HIV infection• Any other medical conditionTell your healthcare provider about all the medicines you take:• Keep a list that includes all prescription and over-the-

counter medicines, vitamins, and herbal supplements, and show it to your healthcare provider.

• Including any medicines containing tenofovir disoproxil fumarate (ATRIPLA®, COMPLERA®, STRIBILD®, TRUVADA®, VIREAD®).

• If you take HARVONI with ribavirin, you should also read the ribavirin Medication Guide for important pregnancy-related information.

HARVONI and certain medicines may affect each other, or cause side effects.

IMPORTANT FACTSThis is only a brief summary of important information about HARVONI and does not replace talking to your healthcare provider about your condition and your treatment.

(har-VOE-nee)

HARVONI is a prescription medicine used with or without ribavirin to treat chronic (lasting a long time) hepatitis C genotype 1, 4, 5 or 6 infection in adults. It is not known if HARVONI is safe and effective in children under 18 years of age.

ABOUT HARVONI

HARVONI, the HARVONI logo, COMPLERA, STRIBILD, TRUVADA, VIREAD, GILEAD and the GILEAD logo are trademarks of Gilead Sciences, Inc., or its related companies. ATRIPLA is a trademark of Bristol-Myers Squibb & Gilead Sciences, LLC. All other trademarks referenced herein are the property of their respective owners. ©2016 Gilead Sciences, Inc. All rights reserved. HVNC0516 03/16

∂ Retail Pharmacy prescription data from IMS NPA New to Brand™ U.S. patient starts between 5/2011 and 12/2015.

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PHYSICIANDIRECTORY

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Francisco J. Baigorri, MD *Gastroenterologist

Simon Behar, MD *Gastroenterologist

Eugenio J. Hernandez, MD *Gastroenterologist

C C 3 C C 5C C 3

C C 1

C C 7

C C 16

C C 11C C 13

C C 14

C C 3

C C 15 C C 18

C C 1

C C 3

C C 6

C C 9

C C 8

C C 2

C C 3

C C 1

C C 10

C C 1 C C 1

Moises E. Hernandez, MD *Gastroenterologist

Barry E. Brand, MDGastroenterologist

Gustavo Calleja, MD *Gastroenterologist

Marc S. Carp, MDGastroenterologist

Jose P. Ferrer Sr., MD *Gastroenterologist

Paul G. Fishbein, MDGastroenterologist

Nelson Garcia Jr., MD *Gastroenterologist

Lewis R. Felder, MDGastroenterologist

Jose P. Ferrer Jr., MD *Gastroenterologist

Edward Feller, MDGastroenterologist

Pamela L. Garjian, MD*Gastroenterologist

Daniel Gelrud, MD *Gastroenterologist

Carla Ginsberg, MDGastroenterologist

Harris I. Goldberg, MDGastroenterologist

Roberto Gonzalez, MD * Gastroenterologist

C C 1

C C 11

Ruben Gonzalez-Vallina, MD * Pediatric Gastroenterologist

Pedro J. Greer Jr., MD *Gastroenterologist

Mitchell Gregg, MD Radiologist, Imaging Center

Guillermo Gubbins, MD * Gastroenterologist

Alfredo J. Hernandez, MD *Gastroenterologist

Enrique Hernandez-Sanchez, MD* Pediatric Gastroenterologist

Richard E. Hernandez, MD *Gastroenterologist

John Ibarra, MD*Radiologist, Imaging Center

Eduardo Krajewski, MD *Colorectal Surgeon

Vicente Lago, MD *Gastroenterologist

Raghad Koutouby, MD Pediatric Gastroenterologist

C C 19C C 12 C C 2

Robert C. Lanoff, MD *Gastroenterologist

11* Habla Español

C C 1

C C 8

C C 1

C C 1 C C 1

C C 17

C C 7

C C 11C C 11

C C 1

C C 2

C C 1

C C 9

C C 7 C C 1

C C 1

C C 9

C C 2

C C 1

C C 1

C C 8

C C 9

C C 7C C 3

C C 2

C C 1

Jose A. Lavergne, MD *Gastroenterologist

Flavia Mendes, MD *Gastroenterologist

Alfredo Rabassa, MD *Gastroenterologist

Eduardo Ruan, MD *Gastroenterologist

James S. Leavitt, MDGastroenterologist

Pedro Morales, MD *Gastroenterologist

Andrew I. Sable, MDGastroenterologist

Marc Lederhandler, MDGastroenterologist

Brett R. Neustater, MDGastroenterologist

S. Lawrence Rothman, MDGastroenterologist

Arie Slomianski, MD *Gastroenterologist

Howard I. Schwartz, MD Gastroenterologist

Jerry Martel, MD, MPH *Gastroenterologist

Javier L. Parra, MD *Gastroenterologist

Marcos Szomstein, MD *Colorectal Surgeon

Andres I. Roig, MD *Gastroenterologist

Somal S. Shah, MD *Gastroenterologist

Jason Slate, MD *Gastroenterologist

Stefania L. Vernace, MDGastroenterologist

George A. Sanchez, MD * Gastroenterologist

Oscar Loret de Mola, MD * Pediatric Gastroenterologist

Irit Ludin-Ullman, MD* Anesthesiologist

Rodolfo Pigalarga, MD*Colorectal Surgeon

Ricardo J. Roman, MD *Gastroenterologist

Gabriel Rodriguez, MD *Anesthesiologist

Seth D. Rosen, MDGastroenterologist

Neil E. Rosenkranz, MDGastroenterologist

Khristian Noto, MD *Colorectal Surgeon

Curtis L. McCarty III, MD Pathology Director

C C 14

Jorge A. Rosario-Mulinelli, MD* Pediatric Gastroenterologist

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Katiuska Iglesias, Pharm D *Specialty Pharmacy Manager

Darlene Boytell-Perez, ARNP * Care Center 1

Rebecca Karousatos, MS, RD, LDN

Care Center 1 & 2

Kayce Tugg, MSN, RNImaging Center

Yamila Akmuradova PA-C *Care Center 11

Ronal R. Ricano, PA-C * Care Center 11

Eugenia Riccombeni, RD, LDN *Care Center 3

Sabrina Kaplan, PA-C * Care Center 1

Jose A. Miguel, PA-C * Care Center 1

Care Centers

Allied Healthcare Staff

Insurances

* Habla Español

Only accepted at our Pediatric Care Centers

AARP Medicare CompleteAetnaAmerican Heritage Life InsuranceAmerican Medical SecurityAvMedBaptist Executive HealthBaptist InternationalBeech streetBHQN Blue Cross Blue ShieldCare Plus (Colorectal only) CignaCoventry Health CareDimensions HealthFirst Health NetworkHealthcare of FloridaHealthease of FloridaHealthSun Health PlansHumanaHumana Champus TricareLeon Medical Center (Colorectal only)Magellan Healthcare Mail Handlers Benefit PlansMedica Health PlanMedicare Part B Molina HealthcareMultiPlanNeighborhood Health PlanPreferred Care PartnersPrestige Health ChoiceSimply HealthcareSunshine HealthUnited HealthcareWellcare / Staywell

Care Center 1 Main Office7500 SW 87 Avenue, Suite 200Miami, FL 33173305-913-0666

Care Center 29555 N. Kendall Drive, Suite 100Miami, FL 33176305-273-7319

Care Center 38950 N. Kendall Drive, Suite 306-WMiami, FL 33176305-596-9966

Care Center 415955 SW 96 Street, Suite 307Miami, FL 33196305-468-4191

Care Center 57765 SW 87 Avenue, Suite 105Miami, FL 33173305-274-0808

Care Center 61400 NE Miami Gardens Drive, Suite 221North Miami Beach, FL 33179305-949-2020

Care Center 7 Main Office16855 NE 2nd Avenue, Suite 202North Miami Beach, FL 33162305-770-0062

Care Center 7 Satellite Office #15803 NW 151 Street, Suite 105Miami Lakes, FL 33014305-770-0062

Care Center 7 Satellite Office #221110 Biscayne Blvd, Suite 206Aventura, FL 33180305-770-0062

Care Center 88200 SW 117 Avenue, Suite 110Miami, FL 33183305-274-5500

Care Center 97765 SW 87 Avenue, Suite 212Miami, FL 33173305-596-3080

Care Center 10475 Biltmore Way, Suite 207-ACoral Gables, FL 33134305-662-6170

Care Center 113661 S. Miami Avenue, Suite 805Miami, FL 33133305-856-7333

Care Center 11 Satellite OfficeFlorida International University 885 SW 109 Avenue, Suite 131Miami, FL 33199305-856-7333

Care Center 12 8525 SW 92nd Street, Suite C-11AMiami, FL 33156305-512-3345

Care Center 139260 SW 72 Street, Suite 217Miami, FL 33173305-271-7330Care Center 149980 Central Park Blvd N., Suite 316Boca Raton, FL 33428561-206-6064

Care Center 158353 SW 124 Street, Suite 203Miami, FL 33156305-259-8720

Jessica Jairala, PA-C * Care Center 1

Noe Tacoronte, PA-C * Care Center 1

Care Center 168353 SW 124 Street, Suite 108Miami, FL 33156305-669-1115

Care Center 177775 SW 87 Avenue, Suite 120Miami, FL 33173305-274-8243

Care Center 188950 N. Kendall Drive, Suite 506W Miami, FL 33176305-595-2710

Care Center 19351 NW 42nd Avenue, Suite 305Miami, FL 33126305-541-1041

Imaging Center7500 SW 87 Avenue, Suite 202Miami, FL 33173305-468-4190

Pathology Laboratory 12485 SW 137 Avenue, Suite 103 Miami, FL 33186 305-468-4194

Specialty Pharmacy7500 SW 87 Avenue, Suite 202Miami, FL 33173305-468-4199

Ellen Matas-Sosa, PA-CCare Center 1

Carol Hernandez, PA-C Care Center 1

Yetzabel Rizo, ARNP * Care Center 1

13Only accepted at our Pediatric Care Centers

as that great or what?! For

those of you who may not

know what I am talking about,

I am referring to the GH Clinical Update

that was held March 2016 at the Biltmore

Hotel. Three years since its revival, this

year’s conference exceeded even my

own lofty expectations. After hearing

all the comments and reading all the

reviews from the previous year, the

necessary adjustments were made to

provide a very informative, current and

useful conference that hopefully made

an immediate impact on patient care.

This year, most of our speakers were

able to bring something new to typical

conference talks and one of my favorite

additions was the “Conference to Clinic”

slide. Everyone listens to the talks and

we all take away what we consider to

be our own personal “nibble” of medical

information we did not know, but

applying it in a practical way isn’t so easy

at times. This takeaway slide written

by the speakers themselves provided

participants with the practical “meat”

of the talk, making it easier for the

information to be brought into practice. 

Also, this year’s agenda brought many

of our GI issues to light through the eyes

of our closest colleagues, surgeons.

While many of the talks have been

predominantly presented by GI’s, the

real world surgical application of many

of the issues we face also need to be

in the forefront of our decision making.

Very important points were made as to

the involvement of a surgical opinion,

as well as the timing of when to obtain

that opinion, so as to act in the best

interest of the patient, and in the most

efficacious way possible (whether

it be in the realm of obesity, fecal

incontinence, biliary disease, or even

transplantation).

But the proverbia l fun and

improvements did not stop there.

We increased our venue size to

accommodate both the increasing

number of participants as well as

the vendors who so graciously were

a part of our event. Ample time was

provided to relax during breaks, catch

up with old colleagues and forge new

relationships while becoming informed

about all the latest medications, tests

and medical devices to provide 21st

century care to our patients.

Yet our work is never done. As you read

this, we are already working towards

an even better GH Clinical Update for

next year. Mark your calendars, save

the date and bring a friend because

I expect to see all of you at the next

conference on February 25, 2017.

See you then!

BY Jerry Martel, MD, MPHGastroenterologist

GH Clinical Update

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loating, or the feeling or having

a distended abdomen full of

gas, is an extremely common

complaint heard in gastroenterology

offices, by pediatricians and family

medicine doctors.

Many diseases can cause bloating

and doctors are relatively proficient

at detecting potential causes of this

condition such as (Celiac disease,

lactose intolerance and bacterial

overgrowth), but in many cases the

tests yield negative results.

Eventually, many patients are labeled as

having “irritable bowel syndrome” (IBS)

and are prescribed generic treatments

that include probiotics, antispasmodics

or peppermint oil. Yet many times they

do not improve and continue to suffer

from their symptoms.

Up to 40% of patients with IBS actually

suffer from sucrose intolerance, formally

known as genetic sucrase-isomaltase

deficiency, or GSID.

Sucrose is formed when the sugars

glucose and fructose bind together.

In order to break this bond, humans

need the presence of an enzyme called

sucrase, which is present in the lining of

small bowel.

Unfortunately, many children are born

with a reduced amount of this enzyme

and the result is that sucrose is not

absorbed and continues traveling down

the bowel. This pulls water from the

intestinal lining cells (causing diarrhea

and cramps) and when it eventually

reaches the large intestine, the bacteria

ferments the sugar and forms hydrogen

gas, which leads to bloating.

Unless your physician orders a sucrose

breath test, or disaccharides analysis

(a test from tissue obtained during an

upper endoscopy which is the best way

to diagnose sucrose intolerance), you

will probably remain undiagnosed for a

long time.

The most frustrating thing of all is

that effective therapy is available.

Treatment begins with a restriction of

sucrose in your diet (which is present

in certain fruits, juices, sugar cane,

syrups, honey and candy), adding a

probiotic containing saccharomyces

boulardii (Florastor) and for most

patients, a medication called Sucraid,

BY Enrique Hernandez-Sanchez, MDPediatric Gastroenterologist

Bloating and Sucrose Intolerance: The Missing Link

which contains the actual missing

enzyme, sucrose.

Patients usually will add 1-2ml of

Sucraid to each meal or snack that

contains sucrose to prevent the

development of symptoms.

If you, your family or friends suffer

from bloating, ask your physician to

be tested for this very common, but

frequently missed condition!

B

305.444.8350Direct Inquiries to Luis Quiñones lq@bentrust.com or Neil Verdeja nverdeja@bentrust.com

At Brown & Brown, we know that we must be as agile as the cheetah in order to thrive in the competitive insurance environment. Brown & Brown is one of the largest and most respected independent insurance intermediaries in the nation, with over 70 years of continuous service and more than 275 locations. Some of our services include:

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date night. the big game.dinner party.

Uses of ENTYVIO® (vedolizumab):ENTYVIO is a prescription medicine used in adults:

• With moderate to severe ulcerative colitis (UC) when certain other UC medicines have not worked well enough or cannot be tolerated. ENTYVIO may help to: begin reducing some symptoms, induce and maintain remission, reduce or stop the use of corticosteroids, and improve the way the lining of your large intestine looks to your healthcare provider.

• With moderate to severe Crohn’s disease (CD) when certain other CD medicines have not worked well enough or cannot be tolerated. ENTYVIO may help to: begin reducing some symptoms, achieve remission, and reduce or stop the use of corticosteroids.

Important Safety Information about ENTYVIO®

• Do not receive ENTYVIO if you have had an allergic reaction to ENTYVIO or any of its ingredients.

• ENTYVIO may cause serious side effects, including:

• Infusion and serious allergic reactions can happen while you are receiving ENTYVIO or several hours after treatment. You may need treatment if you

have an allergic reaction. Tell your healthcare provider or get immediate medical help if you get any of these symptoms during or after an infusion of ENTYVIO: rash; itching; swelling of your lips, tongue, throat or face; shortness of breath or trouble breathing; wheezing; dizziness; feeling hot; or palpitations (feel like your heart is racing).

• ENTYVIO may increase your risk of getting a serious infection. Before receiving and during treatment with ENTYVIO, tell your healthcare provider if you think you have an infection or symptoms of an infection, such as fever, chills, muscle aches, cough, shortness of breath, runny nose, sore throat, red or painful skin or sores on your body, tiredness, or pain during urination.

• Although it has not been reported with ENTYVIO, it may be possible for a person to get progressive multifocal leukoencephalopathy (PML) (a rare, serious brain infection caused by a virus). People with weakened immune systems can get PML, which can result in death or severe disability. There is no known treatment, prevention, or cure for PML. Tell your healthcare provider right away if you have any of the following symptoms:

confusion or problems thinking, loss of balance, change in the way you walk or talk, decreased strength or weakness on one side of the body, blurred vision, or loss of vision.

• Liver problems can happen in people who receive ENTYVIO. Tell your healthcare provider right away if you have any of the following symptoms: tiredness, loss of appetite, pain on the right side of your abdomen, dark urine, or yellowing of the skin and eyes (jaundice).

• The most common side effects of ENTYVIO include common cold, headache, joint pain, nausea, fever, infections of the nose and throat, tiredness, cough, bronchitis, flu, back pain, rash, itching, sinus infection, throat pain, and pain in extremities. These are not all the possible side effects of ENTYVIO. Call your healthcare provider for medical advice about side effects.

• Before receiving ENTYVIO, tell your healthcare provider about all of your medical conditions, including if you: have or think you may have an infection or have infections that keep coming back; have liver problems; have tuberculosis (TB)

or have been in close contact with someone with TB; have recently received or are scheduled to receive a vaccine; or if you are pregnant, breastfeeding, plan to become pregnant, or plan to breastfeed.

Please see the Medication Guide for ENTYVIO on the adjacent page and talk with your healthcare provider.

You are encouraged to report negative side effects of prescription drugs to the FDA.

Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

ENTYVIO is a trademark of Millennium Pharmaceuticals, Inc., registered with the U.S. Patent and Trademark Office, and is used under license by Takeda Pharmaceuticals America, Inc.

Relief and Remission within reach.Learn more at ENTYVIO.com

If other treatments haven’t worked well enough, ask your gastroenterologist about ENTYVIO.®

• DevelopeD only for UC anD Crohn’s • GI-foCUseD• proven to provIDe relIef anD remIssIon

Individual results may vary.

Moderate to severeUlCeratIve ColItIs or Crohn’s syMptoMs leaving you with the saMe view?

it may be time for a different perspective.

© 2016 Takeda Pharmaceuticals U.S.A., Inc. All rights reserved. Printed in U.S.A./June 2016 USD/VED/15/0279c

102695_USDVED150279c_Entyvio_v2TakedaApril 27, 2016 10:04 AM jmd

USD/VED/150279c_Entyvio

date night. the big game.dinner party.

Uses of ENTYVIO® (vedolizumab):ENTYVIO is a prescription medicine used in adults:

• With moderate to severe ulcerative colitis (UC) when certain other UC medicines have not worked well enough or cannot be tolerated. ENTYVIO may help to: begin reducing some symptoms, induce and maintain remission, reduce or stop the use of corticosteroids, and improve the way the lining of your large intestine looks to your healthcare provider.

• With moderate to severe Crohn’s disease (CD) when certain other CD medicines have not worked well enough or cannot be tolerated. ENTYVIO may help to: begin reducing some symptoms, achieve remission, and reduce or stop the use of corticosteroids.

Important Safety Information about ENTYVIO®

• Do not receive ENTYVIO if you have had an allergic reaction to ENTYVIO or any of its ingredients.

• ENTYVIO may cause serious side effects, including:

• Infusion and serious allergic reactions can happen while you are receiving ENTYVIO or several hours after treatment. You may need treatment if you

have an allergic reaction. Tell your healthcare provider or get immediate medical help if you get any of these symptoms during or after an infusion of ENTYVIO: rash; itching; swelling of your lips, tongue, throat or face; shortness of breath or trouble breathing; wheezing; dizziness; feeling hot; or palpitations (feel like your heart is racing).

• ENTYVIO may increase your risk of getting a serious infection. Before receiving and during treatment with ENTYVIO, tell your healthcare provider if you think you have an infection or symptoms of an infection, such as fever, chills, muscle aches, cough, shortness of breath, runny nose, sore throat, red or painful skin or sores on your body, tiredness, or pain during urination.

• Although it has not been reported with ENTYVIO, it may be possible for a person to get progressive multifocal leukoencephalopathy (PML) (a rare, serious brain infection caused by a virus). People with weakened immune systems can get PML, which can result in death or severe disability. There is no known treatment, prevention, or cure for PML. Tell your healthcare provider right away if you have any of the following symptoms:

confusion or problems thinking, loss of balance, change in the way you walk or talk, decreased strength or weakness on one side of the body, blurred vision, or loss of vision.

• Liver problems can happen in people who receive ENTYVIO. Tell your healthcare provider right away if you have any of the following symptoms: tiredness, loss of appetite, pain on the right side of your abdomen, dark urine, or yellowing of the skin and eyes (jaundice).

• The most common side effects of ENTYVIO include common cold, headache, joint pain, nausea, fever, infections of the nose and throat, tiredness, cough, bronchitis, flu, back pain, rash, itching, sinus infection, throat pain, and pain in extremities. These are not all the possible side effects of ENTYVIO. Call your healthcare provider for medical advice about side effects.

• Before receiving ENTYVIO, tell your healthcare provider about all of your medical conditions, including if you: have or think you may have an infection or have infections that keep coming back; have liver problems; have tuberculosis (TB)

or have been in close contact with someone with TB; have recently received or are scheduled to receive a vaccine; or if you are pregnant, breastfeeding, plan to become pregnant, or plan to breastfeed.

Please see the Medication Guide for ENTYVIO on the adjacent page and talk with your healthcare provider.

You are encouraged to report negative side effects of prescription drugs to the FDA.

Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

ENTYVIO is a trademark of Millennium Pharmaceuticals, Inc., registered with the U.S. Patent and Trademark Office, and is used under license by Takeda Pharmaceuticals America, Inc.

Relief and Remission within reach.Learn more at ENTYVIO.com

If other treatments haven’t worked well enough, ask your gastroenterologist about ENTYVIO.®

• DevelopeD only for UC anD Crohn’s • GI-foCUseD• proven to provIDe relIef anD remIssIon

Individual results may vary.

Moderate to severeUlCeratIve ColItIs or Crohn’s syMptoMs leaving you with the saMe view?

it may be time for a different perspective.

© 2016 Takeda Pharmaceuticals U.S.A., Inc. All rights reserved. Printed in U.S.A./June 2016 USD/VED/15/0279c

102695_USDVED150279c_Entyvio_v2TakedaApril 27, 2016 10:04 AM jmd

USD/VED/150279c_Entyvio

Medication GuideENTYVIO (en ti' vee oh)

(vedolizumab)What is the most important information I should know about ENTYVIO?ENTYVIO may cause serious side effects, including: • Infusion and serious allergic reactions. These reactions can

happen while you are receiving ENTYVIO or several hours after treatment. You may need treatment if you have an allergic reaction. Tell your healthcare provider or get medical help right away if you get any of these symptoms during or after an infusion of ENTYVIO: rash, itching, swelling of your lips, tongue throat or face, shortness of breath or trouble breathing, wheezing, dizziness, feeling hot, or palpitations (feel like your heart is racing).

• Infections. ENTYVIO may increase your risk of getting a serious infection. Before receiving ENTYVIO and during treatment with ENTYVIO, tell your healthcare provider if you think you have an infection or have symptoms of an infection such as fever, chills, muscle aches, cough, shortness of breath, runny nose, sore throat, red or painful skin or sores on your body, tiredness, or pain during urination.

• Progressive Multifocal Leukoencephalopathy (PML). Although it has not been reported with ENTYVIO, it may be possible for a person to get progressive multifocal leukoencephalopathy (PML) (a rare, serious brain infection caused by a virus). People with weakened immune systems can get PML. PML can result in death or severe disability. There is no known treatment, prevention, or cure for PML. Tell your healthcare provider right away if you have any of the following symptoms: confusion or problems thinking, loss of balance, change in the way you walk or talk, decreased strength or weakness on one side of the body, blurred vision, or loss of vision.

• Liver Problems. Liver problems can happen in people who receive ENTYVIO. Tell your healthcare provider right away if you have any of the following symptoms: tiredness, loss of appetite, pain on the right side of your stomach (abdomen), dark urine, or yellowing of the skin and eyes (jaundice).

See “What are the possible side effects of ENTYVIO?” for more information about side effects.What is ENTYVIO?ENTYVIO is a prescription medicine used in adults:

• with moderate to severe active ulcerative colitis (UC) when certain other UC medicines have not worked well enough or cannot be tolerated:

° to begin helping some of your symptoms ° in people who respond to ENTYVIO, to help get UC under control (induce remission) and keep UC under control (maintain remission)

° for people who respond to ENTYVIO, you may be able to reduce or stop the use of corticosteroid medicines

° to improve the way the lining of your large intestine looks to your healthcare provider during colonoscopy

• with moderate to severe active Crohn’s disease when certain other Crohn’s disease medicines have not worked well enough or cannot be tolerated:

° to begin helping some of your symptoms ° in people who respond to ENTYVIO, to help get Crohn’s disease under control (achieve remission)

° for people who respond to ENTYVIO, you may be able to reduce or stop the use of corticosteroid medicines

It is not known if ENTYVIO is safe and effective in children under 18 years of age.Who should not receive ENTYVIO?Do not receive ENTYVIO if you have had an allergic reaction to ENTYVIO or any of the ingredients in ENTYVIO. See the end of this Medication Guide for a complete list of ingredients in ENTYVIO.

Before receiving ENTYVIO, tell your healthcare provider about all of your medical conditions, including if you:

• have an infection, think you may have an infection or have infections that keep coming back (see “What is the most important information I should know about ENTYVIO?”).

• have liver problems • have tuberculosis (TB) or have been in close contact with

someone with TB. • have recently received or are scheduled to receive a vaccine.

Talk to your healthcare provider about bringing your vaccines up-to-date before starting treatment with ENTYVIO.

• are pregnant or plan to become pregnant. It is not known if ENTYVIO will harm your unborn baby. Tell your healthcare provider right away if you become pregnant while receiving ENTYVIO.

• are breastfeeding or plan to breastfeed. It is not known if ENTYVIO passes into your breast milk.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. Especially tell your healthcare provider if you take or have recently taken Tysabri (natalizumab), a Tumor Necrosis Factor (TNF) blocker medicine, a medicine that weakens your immune system (immunosuppressant), or corticosteroid medicine.How will I receive ENTYVIO?

• ENTYVIO is given through a needle placed in a vein (intravenous infusion) in your arm.

• ENTYVIO is given to you over a period of about 30 minutes. • Your healthcare provider will monitor you during and after the

ENTYVIO infusion for side effects to see if you have a reaction to the treatment.

What are the possible side effects of ENTYVIO?ENTYVIO may cause serious side effects, See “What is the most important information I should know about ENTYVIO?”The most common side effects of ENTYVIO include: common cold, headache, joint pain, nausea, fever, infections of the nose and throat, tiredness, cough, bronchitis, flu, back pain, rash, itching, sinus infection, throat pain, and pain in extremities.These are not all of the possible side effects of ENTYVIO.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.General information about ENTYVIOMedicines are sometimes prescribed for purposes other than those listed in a Medication Guide. You can ask your pharmacist or healthcare provider for information about ENTYVIO that is written for health professionals. Do not use ENTYVIO for a condition for which it was not prescribed. What are the ingredients in ENTYVIO?Active ingredient: vedolizumabInactive ingredients: L-histidine, L-histidine monohydrochloride, L-arginine hydrochloride, sucrose and polysorbate 80Distributed by:Takeda Pharmaceuticals America, Inc.Deerfield, IL 60015U.S. License No. 1898For more information, go to www.ENTYVIO.com or call 1-877-825-3327This Medication Guide has been approved by the U.S. Food and Drug Administration.Issued: May 2014ENTYVIO is a trademark of Millennium Pharmaceuticals Inc. and is used under license by Takeda Pharmaceuticals America, Inc.All other trademark names are the property of their respective owners.©2014 Takeda Pharmaceuticals America, Inc.VMB245 R1_CFBS L-BZV-0514-4

USD/VED/150279c_Entyvio102695_USDVED150279c_Entyvio_v2TakedaApril 27, 2016jmd

19

astro Health offers an opportunity to participate in clinical trials for new medications. By volunteering

to participate, our patients can help others by contributing to medical research.

Our physicians have participated in the development of many important products for the treatment of gastrointestinal conditions. For example, our team has been involved in the clinical trials for Remicade, Humira, Amitizia, Lialda, Asacol, Osmoprep, Harvoni and Sovaldi.

Today, all new drugs or medical devices need to go through extensive testing prior to being approved for use by patients. In order to come to the market a medication or device needs to go through preclinical trials, which are used to evaluate the safety and potential effectiveness in experimental models. If the drug or device seems promising, it then goes into clinical testing, which consists of the following four phases.

PHASE 1 These studies determine the safety and dosing schedule in healthy volunteers who generally have no medical issues and are paid to take the drug in order to evaluate its safety.

PHASE 2 These studies involve between 150 – 400 subjects to determine if a drug works for a specific condition and to gather additional safety data.

PHASE 3 These studies are considered pivotal in the approval process. They involve from 500-3000 subjects and are what is generally used by the FDA and other government agencies to see if a drug works for a specific disease and if it is safe to use.

PHASE 4 These studies generally are used to evaluate the safety of a medication after it has been approved to go on the market.Before participating in a clinical trial you will

be asked to sign an informed consent approved by an Independent Review Board (IRB) that approves the conduct of the study and make sure it conforms to the principles of the Declaration of Helsinki and FDA guidelines. For further details you can visit www.fda.gov.

An informed consent is required to provide you with the following information:

The purpose of the study.

How long the study will last and the number and frequency of visits required.

Procedures and tests that may be required by participating in the study.The potential risks and benefits of study medication.

Other treatment options that may be available.

BY Howard Schwartz, MD, AGAFGastroenterologist

Participate in Clinical Research and Help Make a Difference for the Future

If there is a chance that subjects participating in a study receive a placebo.

Who will have access to your medical records.

Who will pay for medical care if you are injured in the study.

Awareness that as a research volunteer you can stop your participation at any time without bias.

We are currently conducting a clinical trial comparing Humira to Entyvio in patients with ulcerative colitis. If you would like further information please contact Dr. Howard Schwartz or Karla A. Gonzalez, MA, CCRC at 305-913-0666 ext 1360.

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ne of the most fascinating recent

developments in medicine is our

discovery of the importance of

the microbiome in health and disease.

What is this microbiome and how does

it affect our lives?

Over the last few years researchers

have begun to discern the role of the

microbiome in maintaining health and

its alteration in causing many illnesses.

It is well known that we harbor many

microorganisms within our digestive

BY Paul G. Fishbein, MD, FACP, AGAFGastroenterologist

The Importance of Our Microbiome

tract. In fact, it is estimated that our

gut contains over ten trillion microbes,

most of which reside in our colon. These

include vast numbers of bacteria,

but also fungi, viruses and protozoa.

These microorganisms comprise the

microbiota and their genetic material is

called the microbiome.

The microbiota has evolved in a

Darwinian fashion to relate to us—their

host—in various ways. Most live as

commensals. These organisms thrive

in our gut but do not affect our health

in any meaningful way. Many others,

however, are symbionts. These not only

grow and multiply within our digestive

tract, but also provide benefits to us by

assisting in digestion and promoting a

healthy immune status to maintain our

good health. Finally, there are microbes

that are pathobionts. These invade our

gut and lead to various infections such

as traveler’s diarrhea, gastroenteritis

or colitis. But they can also cause or

aggravate many systemic diseases.

The intestinal microbiota is intimately

involved with the maturation of our gut

after birth. Experiments in mice have

demonstrated that altered microbiota

may have a detrimental effect on the

intestinal surface, lymphoid function,

motility, metabolic processes and

mucosal immunity of our digestive tract.

Normally, these microorganisms defend

us against pathogens. They assist in

energy utilization and the digestion and

absorption of nutrients. They also play

an important role in drug metabolism.

However, when the microbiome is

altered, a dysbiosis develops. When

this occurs, a derangement in the

number and kind of microbiota leads to

various diseases. Small bowel bacterial

overgrowth, Clostridium difficile colitis,

inflammatory bowel disease and irritable

bowel syndrome are prime examples

that have been shown to be affected and

perhaps caused by this dysbiosis. Even

chronic constipation has been attributed

to an altered microbiome.

21

Moreover, malignancies both within the gut and in other

parts of our bodies have been linked to alterations in our

microbiome. One example of this is the development

of gastric cancer from chronic Helicobacter pylori

infection. Importantly, many other serious illnesses

are also associated with this modification in our gut

flora. These include: arthritis, asthma, autism, diabetes

mellitus, fibromyalgia, coronary heart disease, metabolic

syndrome, mood disorders, fatty liver disease and even

such neurologic diseases such as multiple sclerosis and

Parkinson’s disease. Obesity itself has also been said to

be a product of this dysbiosis. It has been demonstrated

that antibiotic use in infants prior to age two contributes

to obesity in later life. Experiments in mice have confirmed

this observation.

It is well known that chronic irritable bowel syndrome

can follow an attack of acute gastroenteritis. It is possible

that change in the microbiota alters the normal function

of the bowel to affect motility and visceral sensitivity.

Once this process occurs, it may be difficult to correct.

Current studies suggest a possible role for probiotics in

preventing and treating this illness.

Ironically, the tremendous medical and scientific

advancements of the 20th century in understanding

and treating diseases, such as the use of antibiotics

and better sanitation, have possibly led to causing new

illnesses or aggravating other pathologic conditions.

We have disturbed the unique balance of symbiosis

with our microbiota which nature created over

millennia.

Now, the 21st century holds out the promise to cure or

prevent many of these diseases by identifying and correcting

alterations in our microbiome. We are learning about

the effects on our macro or external environment from

manufacturing and pollution in causing global warming.

It is our task to discover more about the relationship with

our microbiome and how it affects our lives and health.

Antibiotics, other medications and even the processed

foods we eat have disrupted and damaged our micro or

internal environment. Nature rewards diversity.

Just as a nation, political party or financial portfolio is

stronger with diversity, so too is our microbiome. We must

find ways of reversing this change in order to enhance our

long term health. This challenge of restoring the balance

of our microbiome is one of the most important ones

facing us today.

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AFLD is an increasingly

common chronic disease

of the liver. This condition

occurs in patients who have developed

fat in their liver (steatosis) and in

patients who have developed a chronic

inflammation or scarring of the liver

(fibrosis). The presence of both fat and

fibrosis in the liver is called nonalcoholic

steatohepatitis (NASH). NAFLD has

been reported to be present in around

45% of the U.S. population, while NASH

is seen in 5%. NAFLD is especially more

common in patients who also have

been diagnosed with diabetes, obesity

and high cholesterol. NAFLD does not

present with any typical symptoms as

it’s usually discovered incidentally in

patients with elevated liver function tests

or through imaging tests done for other

reasons. The most common imaging

test is an abdominal ultrasound, while an

MRI is the most accurate imaging test to

detect NAFLD. Until recently, the only

way to both diagnose and assess the

severity of liver fibrosis was through a

liver biopsy. However, there is a new type

of ultrasound called a liver elastrography

that uses sound waves against the liver

to accurately determine the extent of

liver fibrosis. In addition, there are blood

tests such as the Fibrosure test that can

accurately calculate a fibrosis score.

The diagnosis of NASH is important

because if untreated it can lead to major

complications including hepatocellular

carcinoma, liver cirrhosis and possible

death. The main lifestyle modifications

to treat NASH include aggressive weight

loss and avoiding both alcohol and

BY Somal S. Shah, MDGastroenterologist

Non-Alcoholic Fatty Liver Disease (NAFLD)

N

medications that can be toxic to the liver

(such as excessive amounts of Tylenol).

The main option in terms of medical

treatment is vitamin E which works

to decrease the inflammation caused

by the presence of fat in the liver. For

patients with both diabetes and NASH,

the treatment of choice is a class of

diabetes drugs called thiazolidinediones.

Excess weight loss remains far superior

to medications in treating NASH. In fact,

many patients are cured from NASH

after having weight loss surgery such

as a gastric bypass. Since obesity is

likely to become even more common

in the future, there is no doubt that

NASH and its complications will become

increasingly problematic as well.

A not-for-profit organization supported by philanthropy and committed to our faith-based charitable mission of medical excellence

Galloway Endoscopy Center is an accredited surgical facility offering diagnostic and therapeutic gastrointestinal procedures in a comfortable and convenient outpatient setting. Our compassionate, bilingual staff provides top-quality care while assisting our experienced and highly skilled doctors.

A division of Baptist Surgery and Endoscopy Centers 7500 SW 87 Avenue, Suite 101 Miami

GallowayEndoscopy.com 305-595-9511

Best of all, because of advances in medical technology, endoscopic procedures can be safely performed outside the hospital, so you can return to the comfort of your home the same day as your procedure. You have a choice in healthcare. Isn’t it time you got treated better?

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he advent of specialty pharmacies

began roughly 30 years ago and

continues to be a major player in

the healthcare system today. These types

of pharmacies focus on highly specialized

medication therapy for patients with

complex diseases such as hepatitis C,

inflammatory bowel diseases and cancer

to name a few. As the name implies,

the medications filled at these types of

pharmacies require an escalated level

of clinical attention involving ongoing

monitoring, patient education and patient

management by well qualified clinical

staff. They often times require special

handling and storage, as well as specific

administration requirements such as

injections or infusions. This complexity

drives the cost of the medication up,

which oftentimes can exceed $10,000

annually for certain therapies. All of

these factors lend to the need for a

more focused practice of a pharmacy-

based-on-patients that encompasses all

aspects of the patient’s therapy. Specialty

pharmacies are specifically designed to

manage complex patient therapies while

controlling drug spending and waste.

Additionally, specialty pharmacies offer

services that go above and beyond

a traditional retail pharmacy. Making

sure patients have access to these

costly medications is of the utmost

priority. Often times these pharmacies

have specific teams dedicated solely

to patient financial assistance. These

teams have extensive experience in

obtaining authorizations from third

party payers as they are well-versed

in all the requirements needed to

obtain approvals. Moreover, they are

also experts in helping with financial

assistance to help cover the high copays

that are often times associated with

these therapies. The financial assistance

offered is personalized, detailed and

ranges from seeking manufacturer copay

cards to applying for specific charitable

foundations that are crucial to patient

accessibility of these medications.

Gastro Health Specialty Pharmacy is

proud to be a part of this niche area of

pharmacy. In addition to all the services

that a specialty pharmacy provides,

Gastro Health Specialty Pharmacy is

unique in that it is a part of your Gastro

Health clinical provider’s team. The

clinical pharmacy staff has direct access

to your healthcare provider and allied

staff members, as well as has access

to patient records to provide a more

integrated approach to patient therapy.

BY Katiuska Iglesias, Pharm DSpecialty Pharmacy Manager

The Role of the Specialty Pharmacy

This integration allows the pharmacy staff

all the critical patient information needed

to make appropriate clinical decisions as

well as expedite all third party payer claim

requirements. Patients of Gastro Health

Specialty Pharmacy have the advantage

of having their multidisciplinary clinical

team working together to manage their

complex condition.

Specialty pharmacy is a rapidly expanding

field that has now grown to over 200

pharmacies and is still growing. With the

advancement in medication therapy for

complex, rare and chronic conditions there

is an obvious need for the specialized

services they provide. Specialty pharmacies

will continue to meet the challenges of

this rapidly evolving field of healthcare.

T

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PEOPLE. PASSION. POSSIBILITIES.

©2015 AbbVie Inc. North Chicago, IL 60064 64E-1811604 November 2015 Printed in U.S.A.

ADDRESSING THE TOUGHEST CHALLENGES IN GASTROENTEROLOGY

TAKES ALL OF USFor over a decade, we’ve worked closely with physicians, investigators, and patients to take on the toughest health challenges. We’re studying new indications to address significant unmet needs. Creating programs proven to improve patient outcomes. Investing in next-generation research to keep advancing the frontiers of patient care. We’re determined to keep making a difference in gastroenterology. That’s why you can count on our continuing commitment to you and your patients.

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